Ethics Statement
The case itself is the representation of negligence and non-observation of the key safety rules which caused the tragedy. Consequently, the ethical issues that are touched by this report are closely related to the opportunity to prevent similar accidents in the future and provide the proper control system for the companies with potentially dangerous industrial equipment.
Executive Summary
The accident revealed that the victim either did not know how to shut down the machine and how to isolate its energy, or this was simple negligence that cost life to him. The investigation included not only the chronological restoration of the events but also the operational manual of the dough-making machine. Additionally, the safety training procedure had been reviewed to reveal how the accident could take place if the workers were constantly trained, and the safety rules were explained in detail. The investigation concluded that most of the employees are immigrants, and the level of their English is different. Insufficient language skills are regarded as the key reason for the accident, as the victim could not understand all the safety rules.
Introduction
The purpose of the project is to review the accident, reveal the possible reasons that could cause this accident, and create effective safety and control rules for similar organizations to prevent similar accidents. The course of the investigation involved the study of the machine safety documentation, organizational safety rules and practices, as well as the chronology and background of the events. This is required for the proper analysis of the accident, as the instance of murder is rejected. The accident itself is closely linked with the violation of safety rules not only by employees but by employers as well. This is explained by the fact that workers have not been trained properly to shut down the machine, and did not realize the consequences of negligent machine operation.
Research
The quantitative aspect of the accident involves numerous parameters and values of the investigation. In fact, the work with potentially dangerous machinery may require increased attention and additional insurance actions and tests. Hence, the 54-year aged worker could not have the sufficient attention level, and his health condition could be far from norms. The fatal error was the left of the switch on “auto” position. This cause the automating turning on of the blade system, while the employee was inside the elevator hopper. The co-worker, one of the Chinese employees, helped the victim to clean the machine and had to raise the dough bowl for cleaning this part of the machinery.
Everything happened within several minutes, when the co-worker prepared to clean the bowl and asked the victim to pass him the keys. When the power switch was turned on, the auto detector considered that the elevator is loaded, and the blade was launched. Hence, the double negligence cost a life.
Considering the fact that the victim had been working for the company for five years, he should know the basic safety rules, as the company arranged safety training annually. On the other hand, the co-worker did not have sufficient language knowledge, and the company did not care about interpreters for the training process.
Actually, the power of the blade motor is sufficient for making deadly injuries. And the 3/4 HP of the electrical motor became more than sufficient for decapitating the victim. The cutting cycle of the blade is 20-30 seconds, hence, the chances of the victim could be large enough if the blade was at the beginning of the cycle, nevertheless, the victim had only several seconds for saving his life, and the co-worker had not realized his mistake until he heard the noise from the victim’s side.
Examples of quantitative information are closely linked with the parameters of the machine. Actually, the safety system is not effective enough, and the fact that the manufacturer decided to refuse from equipping machines with an automatic regime emphasizes the system in general is ineffective. Hence, the manual regime of the machine is the safest at the moment.
Discussion
Considering the mistakes of the investigation, it should be stated that the actual importance of the research is closely linked with the necessity to restore the chronology of the events. In fact, the case reminds murder, as the investigation report does not emphasize whether there were witnesses of the accident in the room and whether someone is able to confirm the co-worker’s testimony. In general, all the facts and statements of the accident have been revealed; however, the actual statement of the accident is rather detailed. The research in the future should pay attention to the safety rule observation by other workers, and their knowledge of the safety measures required for working with similar machinery. (Lutz, 19)
The initial position of the switchers is included in report, however, it is not stated whether the co-worker checked these positions before elevating the bowl. If he did, this would be murder; if he did not, this is culpable negligence. (Lutz, 11) Consequently, the research could be improved seriously if it is applied to solving the problem in the future. The improvements are related to assessing the knowledge level of the other workers, examination of all the workers for their ability to operate machinery they have access to, and increase of the requirements for the employers that own potentially dangerous machinery.
Trade-offs
In comparison with other similar cases, the investigation commission did not check the safety rules that existed before the accident. In fact, it is evident that the workers were not prevented from getting into the point of operation, however, the other ways of cleaning and sanitation serving are not known.
Hence, the commission had to contact the manufacturer and arrange the training campaign for the employers who own similar machines. The essence of the case is that the recommendations had been given, while the ways of implementing these recommendations are unknown. Moreover, the manufacturer had to provide detailed instructions and reminders for the machine. Reminders and warnings are not the most effective solution, however, the chances of the accident could be lower. (OR-FACE; Oregon OSHA; TRIS)
As for the design of the system, it should be constructed with the proper differentiation whether a working material (dough) is inside, or any other object. The sensor may react to the weight of the object that is inside (as a man is heavier than the portion of the dough, there would be no difficulties in implementing this system), and the system would notify overload, if a working personnel is inside. Another sensor may be optical, and react if something is inserted into the machinery that exceeds the normal sizes of the dough portion.
The safety cover should be implemented for sanitary and cleaning works. If it is open, the sensors would not allow the system to turn on, and, independently of the position of the switchers, the blades would stay motionless. Moreover, the sensor should give the signal to blade motor for the blades were placed at the beginning of the cutting cycle, or turned away from the production line. If these principles were observed, turning the system on would cause fewer fatal injuries. (Occupational Health Brach; Graham 45; Braddee, 31)
Another aspect of the construction that may be implemented is the electronic protection of the switching mechanism. Hence, if the machinery is to be cleaned, or any other maintenance works are planned, the machine is turned off. Turning on may be possible only after the input of a specific combination of numbers on the num pad. The combination may be personal for anyone who has access to operate the machinery.
Optical, electronic and weight safety rules are not the overindulgences if lives are endangered. The improved safety rules may violate the manufacturing standards and tempos, however, the observation of these rules may prevent fatalities and excess expenses for the employer. (Higgins, Casini, 33)
As for the PPE usage, this may be the type of improvement. Considering the fact that cleaning and sanitation of the machinery may be featured with essential difficulties, though, the innovative cleaning technique had not been offered, the personal protection devices of every worker may include radio beacons that are inbuilt in working badges or cleaning instruments. If the system registers a radio signal inside the machine, the safety system is turned on. Ultra short waves may be used for this purpose.
Another PPE that is required, had been used by the victim and co-worker. The safety measures that are associated with the accident are not linked with the PPE usage. If the workers were subjected to the jeopardy of blunt trauma, the PPE would be useful. Additional PPE is not required, as the safety reasoning should be focused on the emergency power-off switcher.
Recommendations
Safety recommendations have been stated by the FACE commission, and the recommendations for the construction changes are provided in the Trade-offs chapter. In fact, the actual importance of the changes is stipulated by the fact that technologies develop, and the machinery manufacturers should be the most interested parties in the cases where human life safety is endangered. It is a pity, however most safety rules are written with bloody inks, and the cost of the safety manuals are human lives and injuries. (SHARP)
The recommendations that may be given to employers and employees are to take care of their lives and the lives of co-workers. The recommendations for the investigators are associated with the deeper study of the reasons, as the current case does not presuppose the study of the safety measures accepted within the company, there is no conclusion whether this was the ignoring of the safety rules or simple misunderstanding of the key requirements. The co-worker did not know English properly, and this could be the key reason for his not knowing the safety measurements.
Another option is to perform the entire isolation and de-energizing of the line before the sanitation and maintenance work. This will be helpful for ensuring the workers’ safety, as well as protection from the accidental turning on the system. This option is the most reliable, that is why it was chosen for specifying in the report. As for the matters of reliability and safety of the machinery, it should be emphasized that unconcern is the largest problem in similar cases, hence, it may cost lives and concerns for others.
Conclusion
The alternatives of the investigation process are associated with studying the motifs of the co-worker. Nothing is stated on the matters of intentional murder, as the details are given neither confirm nor reject the version of the murder. However, as for the matters of recommendations and safety policy changes, the investigators have done great work, and all the details of the accident have been disclosed. Hence, any alternatives are required. The actual importance of the safety recommendations, provided by the investigation commission is based on the importance of observing the protection measures, as well as implementing the insurance measures.
Oral Presentation
The work examines the analyzed accident which happened in a food industry company, engaged in pizza dough manufacturing. The 54-year old Taiwanese male suffered from the imperfect safety system of a dough-making machine. The unlocked blade of the dough dividing mechanism caused his partial decapitation and instant death.
The investigation commission revealed that the co-worker had to elevate the dough bowl for cleaning it, and turn the elevator. This launched the blade while the neck of the victim was under the blade. Another aspect of the investigation is the study of the safety training, though, the commission did not pay attention to whether warning and safety reminders had been available on the machinery and near the switchers. Additionally, the manufacturer’s cleaning recommendations are not reviewed.
The paper offers the improvement of the safety measures as well as the construction of the machinery for avoiding similar accidents. As for the alternatives of the investigation offered, nothing important has been missed, hence, the alternatives are not required. In fact, the commission had to pay attention to some additional details, while the actual investigation course was helpful enough for defining the key mistakes as well as violations of the rules.
Works Cited
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Graham, Jerry. Internal Control Plans and Worker Safety Planning Tool. Research Board Business Office. 2006. Web.
Higgins, David. N., Casini, Victor. J., The Fatality Assessment and Control Evaluation program’s role in the prevention of occupational fatalities. Injury Prevention 2001;7(Suppl I):i27–33. Web.
Lutz, Vernon. Fatality Assessment and Control Evaluation (FACE) Report: Volunteer Fire Fighter Dies When Struck By a Bus While Working Along an Interstate Highway in Illinois. National Institute for Occupational Safety and Health. 12. 2009. Web.
Lutz, Vernon. Fatality Assessment and Control Evaluation (FACE) Report: Volunteer Lieutenant Dies After Falling From a Bridge While Attending to a Motor Vehicle Crash in Arkansas. National Institute for Occupational Safety and Health. 10. 2009. Web.
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OR-FACE. Salesman killed when forklift falls off truck loading ramp. Oregon Fatality Assessment and Control Evaluation. 2010. Web.
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SHARP. Fatality Data Summaries. Safety & Heath assessment & Research for Prevention, 2010. Web.
TRIS. Fatality Assessment and Control Evaluation (FACE) Report for New Jersey: Worker Killed in Compressed Air Explosion at a Tire Retread Plant. National Institute for Occupational Safety and Health. 8; 2002. Web.